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The number and proportion of Americans reporting going without or delaying
needed medical care increased sharply between 2003 and 2007, according to findings
from the Center for Studying Health System Changes (HSC) nationally representative
2007 Health Tracking Household Survey. One in five Americans59 million
peoplereported not getting or delaying needed medical care in 2007, up
from one in seven36 million peoplein 2003. While access deteriorated
for both insured and uninsured people, insured people experienced a larger relative
increase in access problems compared with uninsured people. Moreover, access
declined more for people in fair or poor health than for healthier people. In
addition, unmet medical needs increased for low-income children, reversing earlier
trends and widening the access gap with higher-income children. People reporting
access problems increasingly cited cost as an obstacle to needed care, along
with rising rates of health plan and health system barriers.

Access to Needed Medical Care Declines

n 2007, approximately 20 percent of the U.S. populationone
in five peoplereported not getting or delaying needed medical care at
some point in the previous 12 months, up significantly from 14 percentone
in sevenin 2003. The dramatic decline in access between 2003 and 2007
signals a sharp change in Americans access to care, which was relatively stable
between 1997 and 2003, including some gains.1 Increased
health care costs, along with health insurance-related and health system-related
problems, appear to be the major contributor to Americans declining access
to care.

In 2007, more than 23 million people reported going without needed care and
approximately 36 million people delayed seeking care, for a total of 59 million
people reporting access problems, according to findings from HSCs nationally
representative 2007 Health Tracking Household Survey (see Data
Source). The proportion of Americans reporting unmet needs increased by
2.8 percentage points between 2003 and 2007 (5.2% vs. 8%), the equivalent of
about 9.5 million more people going without medical care (see Figure
1 and Supplementary Table 1). The proportion of Americans
delaying needed care increased by 3.9 percentage points between 2003 and 2007
(8.4% vs. 12.3%), the equivalent of 13.5 million more people.

Access Deteriorates for Insured and Uninsured

ninsured people continue to have much higher levels of
unmet medical need and delayed care compared with insured people, and access
for the uninsured decreased between 2003 and 2007 for both uninsured people
with incomes below 200 percent of poverty$41,300 for a family of four
in 2007and above (see Table 1). These findings are
consistent with other HSC research showing declines in physician charity care
and strained safety net capacity to serve uninsured persons resulting from financial
and competitive pressures in health care markets.2

However, insured people also faced large increases in unmet need between 2003
and 2007. In fact, insured people experienced a greater percentage increase
in unmet medical needs compared with uninsured peoplea 62 percent increase
for the insured vs. a 33 percent increase for the uninsured. As a result, ironically,
the access gap between insured and uninsured people narrowed slightly. In 2003,
uninsured people were 3.4 times as likely to report going without care as insured
people and 2.8 times as likely in 2007. Also, increases in unmet need were relatively
consistent across both low- and high-income insured groups. Rising out-of-pocket
costs in the form of higher deductibles, coinsurance and copayments likely account
for much of the increased unmet need among insured people.3
Other HSC research confirms that insured people with greater out-of-pocket medical
costs are more likely to delay or go without needed care.4

Sickest Face More Access Problems

nmet medical needs are greater for people in poor or fair health compared with people in good, very good or excellent health. Sicker people use more health care and, therefore, have more chances to encounter obstacles in getting care. However, access to care worsened the most for people in poor or fair health, a particular concern because sicker people are in greater need of care. Overall, people in poor or fair health with an unmet need increased by 5.1 percentage points between 2003 and 2007 (11.9% vs. 17.0%), compared with an increase of 2.1 percentage points for people in good, very good or excellent health (4.1% vs. 6.2%).

Insured people in poor or fair health experienced more than a 5 percentage point increase in unmet need (9.0% in 2003 vs. 14.2% in 2007), while insured people in good, very good or excellent health experienced a somewhat smaller increase of 1.8 percentage points (3.2% in 2003 vs. 5% in 2007). Uninsured people in poor or fair health reported the greatest access problems among all people in fair or poor health, with one in four reporting in 2007 that they went without needed care.

Childrens Access Declines

s the overall U.S. population experienced increases in
unmet need and delayed care between 2003 and 2007, children were no exception
(see Table 2). Low-income children encountered the greatest
increase in unmet needs among all children, reversing the gains they experienced
between 1997 and 2003. As a consequence, income differences in unmet need for
children were eliminated by 2003, but these disparities returned by 2007.

While gains in access among low-income children between 1997 and 2003 likely
reflect expansions in Medicaid and the State Childrens Health Insurance Program
(SCHIP) that reduced the number of uninsured children, Medicaid and SCHIP enrollment
among low-income children has remained largely unchanged since 2003. Restrictions
on eligibility and enrollment policies by some states, as well as new federal
requirements for Medicaid applicants to document citizenship, may have contributed
to the lack of growth in Medicaid and SCHIP enrollment since 2003.5
At the same time, continued decreases in employer-sponsored coverage have increased
the proportion of low-income children who are uninsured (findings not shown).
In addition, factors affecting the general populations access to carecost
concerns and health plan and health system barrierslikely contributed to increased
access problems for children.

Cost Concerns Intensify

or the 59 million people reporting an access problem, cost
was the most frequently citedand a growingobstacle to care. In 2007, 69 percent
of people who went without or delayed needed care cited worries about cost,
a 3.8 percentage point increase from 2003 (see Supplementary
Table 2).

While cost continued to be the overwhelming concern among uninsured people
(more than 90% of uninsured people reported cost as a barrier across all three
surveys), the increase in cost barriers occurred mostly among insured people.
As mentioned earlier, higher patient cost sharing—people facing higher deductibles
and other increased out-of-pocket expenses for medical services—likely is driving
growing cost concerns among insured people. As the underlying cost of medical
services and insurance premiums have increased, many employers have reduced
benefits and increased patient cost sharing through so-called benefit buy-downs
as a way to moderate large premium increases and pass along more of the cost
increases to employees.6

More Health System and Plan Barriers

fter concerns about costs, health system-related concerns were the next most frequently cited reason for access problems, followed by health plan-related issues. Both health system and health plan barriers to care jumped approximately 9 percentage points between 2003 and 2007.

Although insured people remained more likely than uninsured people to cite
health system issues as reasons for access problems, uninsured people encountered
especially large increases in health system-related access problems between
2003 and 2007, which accounted for most of their overall increase in access
problems. For all people reporting a health-system barrier to care (see Supplementary
Table 3), the greatest increases occurred for the following reasons: inability
to get to the provider when the office was open (10.2 percentage point increase);
inability to get through on the telephone (6.2 percentage point increase); takes
too long to get to the provider (5.8 percentage point increase); and inability
to obtain an appointment soon enough (4.5 percentage point increase).

Increased provider capacity constraints may have contributed to the rise in
health system barriers. A shortage of some types of doctors in different markets,
particularly primary care physicians, could affect peoples ability to get a
timely appointment. Additionally, some physicians are becoming more entrepreneurial
in response to constraints on their incomes, with responses including reducing
the amount of charity care they provide and limiting their availability outside
of normal business hours and over the telephone (a service that is not billable).7
Further, capacity constraints among safety net providers serving low-income
and uninsured people, such as community health centers, may contribute to access
problems.8 In addition, increased difficulties finding
transportation, obtaining leave from work and arranging childcare are potential
explanations for increased difficulties getting to providers, especially for
uninsured people.

The health plan-related barriers that people increasingly cited were that their
health plan would not pay for treatment (9.2 percentage point increase), followed
by the doctor or hospital would not accept their insurance (4.5 percentage point
increase). The return of health plan prior-authorization requirements for certain
services may be a contributing factor.9 Also, rising insurance
deductibles or coinsurance that cause people to be responsible for much or all
of a medical bill may contribute to some people reporting that their health
plan would not pay for the treatment. The increase in people reporting that
their doctor would not accept their insurance may mean more doctors are opting
out of private insurance networks or not accepting new Medicare or Medicaid
patients.

Implications

ollowing relative stability in access to medical care between 1997 and 2003, many Americans access to care deteriorated between 2003 and 2007, including low-income children and people with the greatest health care needs. Particularly striking is that access to care declined the most for people with insurance coveragelikely because of the increasing financial burden associated with out-of-pocket medical expenses. Other issues that began impacting family budgets during 2007, such as rising energy and fuel costs, the home foreclosure crisis, and an expected downturn in the economy likely contributed to growing economic anxiety that caused families to pull back on spending, including for medical care.

The sharp increase in access problems for insured people strongly suggests that the access to medical care that insurance coverage previously guaranteed is declining. Insured people are facing growing cost pressures, including higher out-of-pocket spending for care, more difficulties finding providers who will accept their insurance and renewed limits on what their insurance will cover. An alternative interpretation of these results is that as individuals are exposed to more of the costs of care, they are becoming more efficient users by delaying or forgoing care that may be of low marginal value, which is the key rationale for consumer-directed health care.

The measure of unmet need used in this study does not allow for a determination of the clinical need for care or the potential health consequences of delayed or forgone care. However, the fact that unmet need increased the most for the sickest people should cause concern, as they are the most likely to experience adverse health consequences as a result of disruptions in their medical care use.

Many state and national health reform proposals call for subsidizing the purchase of private insurance coverage, with limits on the total amount of out-of-pocket spending required by individuals and families. Identifying the appropriate threshold of out-of-pocket spending will be crucial to the success of these policies, because setting these thresholds too high may result in financial burdens that will compel individuals to put off or go without needed care.

At the same time, increases in cost-related access problems are a direct result
of health care costs increasing more rapidly than incomes during the past 10
years. Employment-based private insurance premiums increased 114 percent from
1999 to 2007, while average hourly earnings increased 27 percent, leaving a
gap of 6.7 percentage points per year.10 Rising costs
are passed on to individuals and families in the form of higher premiums, deductibles,
coinsurance and copayments for services.

The problems of cost and access are inextricably linked. Without cost containment, expanded government support for insurance coverage will have to keep pace with the trend in medical care spending to maintain affordability for individuals and families. Such increases in health care costs will be difficult for governments to sustain, especially during periods of slow or negative economic growth. To the extent that cost increases are passed on to individuals, continued declines in access to care are inevitable.

Although rising costs continue to be the dominant obstacle to access to needed
care, people face growing barriers related to health care system capacity and
provider accessibility. This is consistent with a perception of growing medical
workforce shortages, especially among primary care practitioners, which will
be difficult for policy makers to address in the short term.11
When such barriers lead to delays in needed care, people ultimately may seek
care in more costly hospital emergency departments with potentially more serious
conditions. Uninsured people face particular health system barriers, since growth
in their numbers push against capacity constraints among safety net providers.
Without resources for safety net providers to keep pace with rising demand for
services, unmet needs and delayed care will likely continue to rise.

Cohen Ross, Donna, Aleya Horn and Caryn Marks, Health Coverage for
Children and Families in Medicaid and SCHIP: State Efforts Face New Hurdles,
The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family
Foundation (January 2008).

Data Source

This Tracking Report presents findings from the HSC 2007 Health Tracking
Household Survey and the Community Tracking Study Household Surveys from 1996-97
and 2003. All three telephone surveys use nationally representative samples
of the civilian, noninstitutionalized population. Sample sizes include about
60,000 people for the 1996-97 survey, about 47,000 people for the 2003, and
about 18,000 people for the 2007 survey. Response rates for the surveys are
65 percent in 1996-97, 57 percent in 2003 and 43 percent in 2007. Population
weights adjust for probability of selection and differences in nonresponse based
on age, sex, race or ethnicity, and education. Although all three surveys are
nationally representative, the samples for the 1996-97 and 2003 surveys were
largely clustered in 60 representative communities, while the 2007 survey was
based on a stratified random sample of the nation. Standard errors account for
the complex sample design of the surveys. Questionnaire design, survey administration
and the question wording of all measures in this study were similar across the
three surveys.

Estimates of unmet need and delayed care were based on the following two
questions: (1) During the past 12 months, was there any time when you didnt
get the medical care you needed? and (2) Was there any time during the past
12 months when you put off or postponed getting medical care that you thought
you needed? For those reporting either an unmet need or delayed care, follow-up
questions were asked to determine why. Responses included worry about cost,
problems with health insurance, problems with availability of medical providers
and personal reasons, such as lack of time or procrastination. This Tracking
Report includes only responses where at least one of the reasons had something
to do with the health care system; responses related to personal reasons only
were not considered as unmet need or delayed care. Insurance status reflects
coverage on the day of the interview and includes coverage obtained through
employer-sponsored and individually purchased private insurance, Medicare, Medicaid,
the State Childrens Health Insurance Program (SCHIP), other state programs,
TRICARE and other military insurance programs, and the Indian Health Service.